Ersin UYSALLAR, SEMRA KARAMAN, İLKBEN GÜNÜŞEN, MELTEM UYAR, Vicdan FIRAT

Sezaryen operasyonlarında kombine spinal epidural blok ile spinal bloğun maternal ve neonatal etkilerinin karşılaştırılması

Amaç: Sezaryen operasyonlarında spinal bloğun güvenirliliği ve epidural bloğun kullanım esnekliklerini içeren kombine spinal-epidural bloğun kullanımı giderek artmaktadır (KSEB). Biz çalışmamızda KSEB ile spinal bloğun maternal ve fetal etkilerini karşılaştırmayı amaçladık. Gereç ve Yöntem: Miyadında 40 gebe randomize olarak iki gruba ayrıldı. KSEB grubuna intratekal 1.5 ml, spinal blok (SB) grubuna 2.5 ml %0.5 hiperbarik bupivakain uygulandı. KSEB grubunda bloğun uygulanmasından itibaren 10 dakika geçmesine rağmen duyusal blok T4’e ulaşmamış ise epidural kateterden her bloke olmayan segment için 2 mL %0.5 bupivakain ilave edildi. Maternal hemodinamik etkiler, intraoperatif anestezi kalitesi ve yan etkiler, Apgar ve NAKS skorları ve postoperatif analjezi yönünden iki grup karşılaştırıldı. Bulgular: Duyusal bloğun T4’e ulaşma zamanı ve tam blok oluşma süresi SB grubunda KSEB’a göre istatistiksel olarak kısa saptandı (p

Comparison of the maternal and neonatal effects of combined spinal-epidural block and spinal block for cesarean section

Objectives: Combined spinal-epidural block (CSEB) has gained increasing interest as it combines the reliability of a spinal block (SB) and the flexibility of an epidural block in cesarean section. We have investigated maternal and fetal effect of CSEB against SB in cesarean operation. Material and Methods: Forty healty, term pregnant women were randomized into two groups. Patients in the CSEB and SB groups were given 1.5 mL and 2.5 mL of 0.5% hyperbaric bupivacaine intrathecally, respectively. If sensorial block did not reach T4 within 10 min, supplemental bupivacaine was injected epidurally 2 mL per unblocked segment in CSEB group. The quality and side effects of surgical anesthesia, hemodynamic parameters, Apgar scores, NACS and postoperative duration of pain were compared between the two groups. Results: The time for the block to rich T4 level was significantly lower in SB group (p<0.05). More patients in the SB group achieved complete motor blockade sooner than in the CSEB group (p<0.05). Mean arterial pressure was lower in SB group (p<0.05). There were no significant differences between the groups in the incidences of apgar scores, cord blood gases, and NACS and adverse effects such as nausea and vomiting. Conclusion: Both spinal and CSE block provide good surgical analgesia for cesarean section. Maternal hypotension is a risk with both technigues, but it occurs earlier and more higher with spinal block. There is no difference in neonatal outcome, provided that maternal blood pressure is cautiously monitored and hypotension promptly treated.

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1. Erdine S, Özyalçın SN, Yücel A. Santral sinir blokları. In: Erdine S, Özyalçın SN, Raj P, Heavner J, Aldemir T, Yücel A, editors. Rejyonal anestezi. İstanbul: Nobel Tıp Kitabevleri; 2005. p. 135-90.
2. Cook TM. Combined spinal-epidural techniques. Anaesthe sia 2000;55(1):42-64.
3. Amiel-Tison C, Barrier G, Shnider SM, Levinson G, Hughes SC, Stefani SJ. A new neurologic and adaptive capacity scor ing system for evaluating obstetric medications in full-term newborns. Anesthesiology 1982;56(5):340-50.
4. Familton MJ, Morgan BM. ‘Needle-through-needle’ tech nique for combined spinal-extradural anaesthesia in obstet rics. Br J Anaesth 1992;68(3):327.
5. Wildsmith JA. Problems with combined spinal and epidural anesthesia. Reg Anesth Pain Med 1998;23(4):388-9.
6. Rawal N, Schollin J, Wesström G. Epidural versus combined spinal epidural block for cesarean section. Acta Anaesthesiol Scand 1988;32(1):61-6.
7. Stocks GM, Hallworth SP, Fernando R, England AJ, Columb MO, Lyons G. Minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl. Anesthesiology 2001;94(4):593-8.
8. Ben-David B, Levin H, Solomon E, Admoni H, Vaida S. Spinal bupivacaine in ambulatory surgery: the effect of saline dilu tion. Anesth Analg 1996;83(4):716-20.
9. Stienstra R, Dahan A, Alhadi BZ, van Kleef JW, Burm AG. Mechanism of action of an epidural top-up in combined spi nal epidural anesthesia. Anesth Analg 1996;83(2):382-6.
10. Klasen J, Junger A, Hartmann B, Benson M, Jost A, Banzhaf A, et al. Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia. Anesth Analg 2003;96(5):1491-5.
11. Karaman S, Akercan F, Akarsu T, Firat V, Ozcan O, Karadadas N. Comparison of the maternal and neonatal effects of epidural block and of combined spinal-epidural block for Cesarean section. Eur J Obstet Gynecol Reprod Biol 2005;121(1):18-23.
12. Takiguchi T, Okano T, Egawa H, Okubo Y, Saito K, Kitajima T. The effect of epidural saline injection on analgesic level dur ing combined spinal and epidural anesthesia assessed clini cally and myelographically. Anesth Analg 1997;85(5):1097-100.
13. Kumar CM. Combined subarachnoid and epidural block for caesarean section. Can J Anaesth 1987;34(3 ( Pt 1)):329-30.
14. Kestin IG. Spinal anaesthesia in obstetrics. Br J Anaesth 1991;66(5):596-607.
15. Goy RW, Chee-Seng Y, Sia AT, Choo-Kok K, Liang S. The median effective dose of intrathecal hyperbaric bupivacaine is larger in the single-shot spinal as compared with the combined spinal-epidural technique. Anesth Analg 2005;100(5):1499-502.
16. Thorén T, Holmström B, Rawal N, Schollin J, Lindeberg S, Skeppner G. Sequential combined spinal epidural block versus spinal block for cesarean section: effects on maternal hypotension and neurobehavioral function of the newborn. Anesth Analg 1994;78(6):1087-92.
17. Shende D, Cooper GM, Bowden MI. The influence of intrathe cal fentanyl on the characteristics of subarachnoid block for caesarean section. Anaesthesia 1998;53(7):706-10.
18. Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R. In cidence and risk factors for side effects of spinal anesthesia. Anesthesiology 1992;76(6):906-16.
19. Choi DH, Park NK, Cho HS, Hahm TS, Chung IS. Effects of epi dural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25(6):591-5.
20. Weeks SK. Postpartum headache. In: Chesnut DH, editor. Ob stetric anesthesia: principles and practice. USA Mosby, Inc.: 2004. p. 478.